1. + Dysphagia: An Overview Adults and Pediatric Population Nadita Maharaj, Certified S&LP, Director and CEO of Talk the Walk Speech & Language Therapy Services. Sirlon George, MS, S&LP and is certified and licensed with the American Speech and Hearing Association and S&LP. Trinidad & Tobago.

2. + What is Dysphagia? Dysphagia: The loss or impaired ability to feed, chew and/or swallow Feeding: The process of getting solids, liquids & medication up and into the mouth Swallowing: The entire act of deglutition, a physiological process that takes solids, liquids, saliva & medication from the mouth to the stomach

3. + DYSPHAGIA  Difficulty Swallowing Swallowing difficulty  frequently associated with : - Stroke - Neurological disease - Head and Neck cancer. In addition, swallowing problems sometimes occur with bacterial, viral, and fungal infections of the upper airway, and surgeries or disease processes that do not directly involve the oral, pharyngeal, or laryngeal structures.

4. + Statistics Up to 30% of alert stroke patients with dysphagia die within the first 6 months following a stroke (compared with 10% without dysphagia) Dysphagia is present in 64-90% conscious stroke patients in the acute phase Dysphagia and aspiration in 22-42% conscious stroke patients in the acute phase Not age-group specific

5. + Swallow is DYNAMIC

6. + The Swallowing Mechanism Central Organisation: Cortex + Brainstem Moderates phases controls reflex, actual eating of swallow and drinking

7. + Stages of Swallowing 1. Oral preparatory phase 2. Oral phase 3. Pharyngeal phase 4. Oesophageal phase

8. + Diagrammatic Illustration of Motor Events of Swallowing Reflex

9. + Signs of Aspiration & Indicators of Dysphagia Acute Spiking temperature Right base of lung signs Wet/gurgly voice Coughing/ choking on food/drink/saliva Change of colour Sounds of respiratory difficulty Gasping Rapid heart rate Watery eyes

10. + Signs of Aspiration & Indicators of Dysphagia Chronic Recurrent chest infections Persistent wet/gurgly voice Coughing/choking on food/drink/saliva Loss of weight Excess of oral secretions Hunger Refuses to eat Dysarthria

11. + Effects of Ageing on Swallowing Ossification of cartilages occur Incidence of arthritis increases Muscular strength decreases and neuromuscular functions slow with age (Kendall et al, 2004) Older adults seen to use a dipper swallow Slightly longer oral and pharyngeal swallow (Kendall et al; 2004 )

12. + Role of the SLP in Adult Dysphagia

13. + SLPs Roles Include: 1) Making recommendations about management of swallowing & feeding disorders 2) Educating other professionals 3) Advocating for services (ASHA, 2002)

14. + Dysphagia: Stroke Best Practice Use a simple, valid, reliable tool before initiating oral intake of medications, fluids or food Assess the swallowing ability of all stroke patients who fail the swallowing screening Clinical Bedside Assessment Instrumental Assessment (e.g. videofluoroscopy swallow study, FEES) Nutritional status – assess using a validated tool or measure, to avoid malnutrition Explain the nature of the dysphagia, recommendations, follow-up & re-ax to patients, family & care providers Provide client and/or legal decision maker with enough info to allow informed decision making Reassess those receiving modified texture diets or enteral feeding for changes in swallowing status

15. + Final Thoughts: Clinical Implications Improve quality of life AdvocateEducatePrevent

16. + Role of the SLP in Pediatric Swallowing Disorders Identify structural, physiological, sensory or behavior based Oral/Pharyngeal/Esophageal deficits that may contribute to the child’s inability to take adequate nutrition orally. Provide recommendations &/or treatment to facilitate a safe means to establish and maintain adequate nutrition orally. Preservation &/or habilitation of oral motor and pharyngeal skills in non-oral feeders.

17. + Common Causes of Dysphagia in Children Developmental disability (i.e., disability with onset before the age of 22 Neurological disorders (e.g., cerebral palsy, meningitis, Factors affecting neuromuscular coordination (e.g., prematurity, low birth weight); Complex medical conditions (e.g., heart disease, Structural abnormalities (e.g., cleft lip and/or palate) Genetiic Syndromes (e.g. Piere Robim Prader-Willi etc) Social Emotional environmental issues

18. + Assessment of Dysphagia SLPs conduct assessments in a manner that is sensitive to the family's cultural background, religious beliefs, and preferences for medical treatment. Families are encouraged to bring food and drink common to their household and utensils/implements typically used by the child Typical feeding practices are observed during assessment

19. + Development of Swallowing in Children 0-4 Months Suck / Swallow / Breathe 4-6 Months With maturation, mandibular growth brings increased space for the tongue. The pharynx elongates with the hyoid, epiglottis, & larynx descending in relation to the soft palate.

20. + Physical Swallowing Examination Structural examination: physical nature of oral-motor structures, looks for asymmetry, drooling, and abnormal patterns or reflexes Functional examination: how the oral-motor structures work together, looks at safety and efficiency and quality of intake If any problems are seen, child may be referred for modified barium swallow study (MBS) – radiography follows a substance through child ’ s swallowing process

21. + Evaluation of Aspiration and/or Dysphagia Difficulty coordinating suck/swallow/breathe sequence. Turning away,crying,arching,&/or fussy behaviors during feeds. Coughing,choking,or throat clearing before/during/after swallow.

22. + Characteristics of Swallowing Disorders in Children Children with feeding/swallowing disorder usually exhibit one or more of the following: Feeding and/or swallowing that is unsafe Feeding and/or swallowing that is inadequate Feeding and/or swallowing that is inappropriate

23. + Unsafe Feeding and Swallowing Unsafe feeding and swallowing poses a risk for penetration or aspiration as well as poor nutrition Unsafe swallowing (dysphagia) results from dysfunction or damage of the child ’ s oral- motor system or an inappropriate eating rate (either too fast or too slow) Unsafe swallowing may result in a physician ’s order for “ nothing per oral ” (NPO): child cannot ingest anything through mouth

24. + Inadequate Feeding/Swallowing Inefficiency: unable to meet caloric and nutritional needs because process of feeding and swallowing is not productive Overselectivity: restrictive in taste, type, texture, and/or volume of foods eaten Refusal: complete refusal to feed, due to ongoing medical issues, gastro-intestinal distress, or traumatic experiences Feeding Delay: delayed development of feeding skill milestones

25. + Inappropriate Feeding/ Swallowing Children exhibit undesirable or disruptive behaviors during mealtimes that inhibits successful feeding Examples: screaming, spitting, throwing, hitting, drop food on the floor, eating at inappropriate rates Eating too slow: nutritional deficiencies Eating too fast: choking or aspiration

26. + Treatment of Dysphagia Multidisciplinary Team: Collaboration of parents, families and professionals working as a team to ensure effectiveness of treatment Most involved professionals: Pediatrician/Physician Nutritionist Speech Language Pathologist

27. + Treatment of Dysphagia Due to the heterogeneity of diagnoses and the complexity of managing dysphagia across the age spectrum, a team approach is often ideal, if not necessary for Dyspahgia management fo both adutls an children Formation of the team begins with involvement of the parents, family and/or caregivers.

28. + References ASHA.org Kendall et al (reference article)

29. + Questions/Comments?